Follow the steps to successfully fill out the NY PAS 123 form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin by filling out the applicant information section. Provide the full name of the applicant, their date of birth, the last four digits of their Social Security number, and the date they were last fingerprinted.
3. Indicate the entity for which the applicant was fingerprinted by filling in the relevant details in the designated field.
4. Proceed to the provider information section. Enter the provider name and provider number. Indicate whether you are a dually licensed provider in New York State by checking the appropriate box for 'Yes' or 'No.'
5. State the job title for which the applicant is applying to complete the employment details.
6. If applicable, provide any additional information that may support the waiver request.
7. In the provider certification section, the undersigned should fill in their name, title, email address, phone number, and date. Remember to sign the document to certify that the information provided is accurate.
8. Finally, ensure all fields are completed before saving your changes. You can then download, print, or share the completed form as needed.

Complete your documents online today for a streamlined experience.